Influence of time-to-diagnosis on time-to-percutaneous coronary intervention for emergency department ST-elevation myocardial infarction patients: Time-to-electrocardiogram matters

Objectives

Earlier electrocardiogram (ECG) acquisition for ST-elevation myocardial infarction (STEMI) is associated with earlier percutaneous coronary intervention (PCI) and better patient outcomes. However, the exact relationship between timely ECG and timely PCI is unclear.

Methods

We quantified the influence of door-to-ECG (D2E) time on ECG-to-PCI balloon (E2B) intervention in this three-year retrospective cohort study, including patients from 10 geographically diverse emergency departments (EDs) co-located with a PCI center. The study included 576 STEMI patients excluding those with a screening ECG before ED arrival or non-diagnostic initial ED ECG. We used a linear mixed-effects model to evaluate D2E's influence on E2B with piecewise linear terms for D2E times associated with time intervals designated as ED intake (0-10 min), triage (11-30 min), and main ED (>30 min). We adjusted for demographic and visit characteristics, past medical history, and included ED location as a random effect.

Results

The median E2B interval was longer (76 vs 68 min, p < 0.001) in patients with D2E >10 min than in those with timely D2E. The proportion of patients identified at the intake, triage, and main ED intervals was 65.8%, 24.9%, and 9.7%, respectively. The D2E and E2B association was statistically significant in the triage phase, where a 1-minute change in D2E was associated with a 1.24-minute change in E2B (95% confidence interval [CI]: 0.44-2.05, p = 0.003).

Conclusion

Reducing D2E is associated with a shorter E2B. Targeting D2E reduction in patients currently diagnosed during triage (11-30 min) may be the greatest opportunity to improve D2B and could enable 24.9% more ED STEMI patients to achieve timely D2E.

Shorter Door-to-ECG Time Is Associated with Improved Mortality in STEMI Patients

Background: Delayed intervention for ST-segment elevation myocardial infarction (STEMI) is associated with higher mortality. The association of door-to-ECG (D2E) with clinical outcomes has not been directly explored in a contemporary US-based population. Methods: This was a three-year, 10-center, retrospective cohort study of ED-diagnosed patients with STEMI comparing mortality between those who received timely (<10 min) vs. untimely (>10 min) diagnostic ECG. Among survivors, we explored left ventricular ejection fraction (LVEF) dysfunction during the STEMI encounter and recovery upon post-discharge follow-up. Results: Mortality was lower among those who received a timely ECG where one-week mortality was 5% (21/420) vs. 10.2% (26/256) among those with untimely ECGs (p = 0.016), and in-hospital mortality was 6.0% (25/420) vs. 10.9% (28/256) (p = 0.028). Data to compare change in LVEF metrics were available in only 24% of patients during the STEMI encounter and 46.5% on discharge follow-up. Conclusions: D2E within 10 min may be associated with a 50% reduction in mortality among ED STEMI patients. LVEF dysfunction is the primary resultant morbidity among STEMI survivors but was infrequently assessed despite low LVEF being an indication for survival-improving therapy. It will be difficult to assess the impact of STEMI care interventions without more consistent LVEF assessment.

Maximizing Equity in Acute Coronary Syndrome Screening across Sociodemographic Characteristics of Patients

We compared four methods to screen emergency department (ED) patients for an early electrocardiogram (ECG) to diagnose ST-elevation myocardial infarction (STEMI) in a 5-year retrospective cohort through observed practice, objective application of screening protocol criteria, a predictive model, and a model augmenting human practice. We measured screening performance by sensitivity, missed acute coronary syndrome (ACS) and STEMI, and the number of ECGs required. Our cohort of 279,132 ED visits included 1397 patients who had a diagnosis of ACS. We found that screening by observed practice augmented with the model delivered the highest sensitivity for detecting ACS (92.9%, 95%CI: 91.4-94.2%) and showed little variation across sex, race, ethnicity, language, and age, demonstrating equity. Although it missed a few cases of ACS (7.6%) and STEMI (4.4%), it did require ECGs on an additional 11.1% of patients compared to current practice. Screening by protocol performed the worst, underdiagnosing young, Black, Native American, Alaskan or Hawaiian/Pacific Islander, and Hispanic patients. Thus, adding a predictive model to augment human practice improved the detection of ACS and STEMI and did so most equitably across the groups. Hence, combining human and model screening--rather than relying on either alone--may maximize ACS screening performance and equity.

Variation in ACS patient hospital resource utilization: Is it time for advanced NSTEMI risk stratification in the ED?

OBJECTIVES

A majority of patients who experience acute coronary syndrome (ACS) initially receive care in the emergency department (ED). Guidelines for care of patients experiencing ACS, specifically ST-segment elevation myocardial infarction (STEMI) are well defined. We examine the utilization of hospital resources between patients with NSTEMI as compared to STEMI and unstable angina (UA). We then make the case that as NSTEMI patients are the majority of ACS cases, there is a great opportunity to risk stratify these patients in the emergency department.

MATERIALS AND METHODS

We examined hospital resource utilization measure between those with STEMI, NSTEMI, and UA. These included hospital length of stay (LOS), any intensive care unit (ICU) care time, and in-hospital mortality.

RESULTS AND CONCLUSIONS

The sample included 284,945 adult ED patients, of whom 1195 experienced ACS. Among the latter, 978 (70%) were diagnosed with NSTEMI, 225 (16%) with STEMI, and 194 with UA (14%). We observed 79.1% of STEMI patients receiving ICU care. 14.4% among NSTEMI patients, and 9.3% among UA patients. NSTEMI patients' mean hospital LOS was 3.7 days. This was shorter than that of non-ACS patients 4.75 days and UA patients 2.99. In-hospital mortality for NSTEMI was 1.6%, compared to, 4.4% for those with STEMI patients and 0% for UA. There are recommendations for risk stratification among NSTEMI patients to evaluate risk for major adverse cardiac events (MACE) that can be used in the ED to guide admission decisions and use of ICU care, thus optimizing care for a majority of ACS patients.

Clinical characteristics, outcomes, and seasonality of acute respiratory infection associated with single and codetected rhinovirus species among hospitalized children in Amman, Jordan

Rhinovirus (RV)-specific surveillance studies in the Middle East are limited. Therefore, we aimed to study the clinical characteristics, outcomes, and seasonality of RV-associated acute respiratory infection among hospitalized young children in Jordan. We conducted a prospective viral surveillance study and enrolled children <2 years old admitted to a large public hospital in Amman, Jordan (2010-2013). Demographic and clinical data were collected by structured interviews and chart abstractions. Nasal and/or throat swabs were collected and tested for a panel of respiratory viruses, and RV genotyping and speciation was performed. At least one virus was detected in 2641/3168 children (83.4%). RV was the second most common virus detected (n = 1238; 46.9%) and was codetected with another respiratory virus in 730 cases (59.0%). Children with RV codetection were more likely than those with RV-only detection to have respiratory distress but had similar outcomes. RV-A accounted for about half of RV-positive cases (54.7%), while children with RV-C had a higher frequency of wheezing and reactive airway disease. RV was detected year-round and peaked during winter. In conclusion, though children with RV codetection had worse clinical findings, neither codetection nor species affected most clinical outcomes.

Clinical presentations of adult and pediatric SARS-CoV-2-positive cases in a community cohort, Nashville, Tennessee

Compared to adults, the prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) illness in children has been lower and less severe. However, reports comparing SARS-CoV-2 infection among children and adults are limited. As part of our longitudinal cohort study of adults and children with SARS-CoV-2 infection and their household contacts in Nashville, Tennessee, we compared the clinical characteristics and outcomes of SARS-CoV-2 infections between children and adults. Children were more likely to be asymptomatically infected and had a shorter illness duration compared to adults. The differences observed in clinical presentation across ages may inform symptom-specific testing, screening, and management algorithms.

The impact of community closures among nonessential and essential workers, Nashville, Tennessee: A cross-sectional study

Background and Aims

The effects of community closures and relaxing social distancing restrictions on severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) by occupational risk remain unclear. Therefore, we evaluated the impact of community closures and reopening phases with the prevalence of testing SARS-CoV-2-positive among nonessential and essential workers.

Methods

We constructed a cross-sectional cohort from March 20 to July 31, 2020, of 344 adults from Metropolitan Nashville, Tennessee. We performed an unconditional logistic regression model to evaluate the impact of community closures and phase implementation on testing SARS-CoV-2 positive by occupation to estimate adjusted prevalence odds ratios (aPORs) and 95% confidence intervals (CIs).

Results

During a stay-at-home/Phase I order, those with non-essential occupations had 59% decreased prevalence odds (aPOR:0.41; 95% CI: 0.20-0.84) of testing SARS-CoV-2-positive compared to when no restrictions were in place. Persons with essential occupations had four times the prevalence odds of testing SARS-CoV-2-positive (aPOR:4.19; 95% CI:1.57-11.18) compared with nonessential occupations when no community restrictions were established.

Conclusion

Stay-at-home restrictions were associated with a lower risk of SARS-CoV-2 infection in the community for nonessential workers. Essential employees remained at increased risk for SARS-CoV-2, including when no community restrictions were in place and vaccines were not available. This study supports targeting prevention measures for these high-risk occupations.

290. Persistence of Long COVID in SARS-CoV-2 Confirmed Cases One-Year Post Infection

Background

Regardless of severity of acute SARS-CoV-2 illness, adults infected with SARS-CoV-2 are at risk for post-acute sequelae of COVID-19. Long COVID is typically classified as symptoms lasting greater than four weeks post-infection. We aimed to evaluate the frequency of resolved and unresolved long COVID symptoms in adults residing in greater Nashville, TN.

Methods

We conducted a longitudinal cohort study of SARS-CoV-2-positive and exposed individuals from March 20 to May 15, 2020. Participants for this analysis were included if: 1) ≥18 years; 2) SARS-CoV-2 positive by molecular or antibody testing; and 3) completed a one-year visit. Demographic and illness information were collected at enrollment, and long COVID symptoms were systematically collected at the one-year survey. Long COVID symptoms are defined as an adult experiencing at least one of the following symptoms four weeks post-infection: fatigue, confusion, loss of smell or taste, shortness of breath, chest pain, cough, muscle aches, inability to exercise, or heart palpitations. Unresolved symptoms are defined as an individual with long COVID still experiencing symptoms at the one-year visit.

Results

A total of 115 adults enrolled and completed the one-year survey, of which 63 (54.8%) were SARS-CoV-2-positive, with one asymptomatic individual. Of SARS-CoV-2-positive symptomatic adults, 32 (51%) were female, 5 (88%) were of Hispanic ethnicity, and 58 (92%) were white. At the one-year visit, 33 (52%) reported having long COVID, of which 17 (52%) reported having unresolved symptoms. Fatigue (89%), headache (89%), muscle aches (79%), and cough (77%) were the most common symptoms reported at illness onset (Figure 1). Among 33 adults with long COVID, fatigue (42%), loss of smell (39%), and loss of taste (33%) were most common (Figure 2A). In the 17 individuals with unresolved symptoms, loss of smell (29%) and loss of taste (24%) were commonly reported (Figure 2B).

Figure 1. COVID-19 symptoms reported at enrollment (n=62)

Figure 2. Long COVID (symptoms lasting ≥ 4 weeks) (n=33) (A) and unresolved long COVID symptoms one-year post-infection (n=17) (B) reported on the one-year survey

Conclusion

Half of the adults in our cohort reported long COVID symptoms, with more than quarter of symptoms persisting one-year post-illness. Our findings support that prolonged symptoms up to year after SARS-CoV-2 exposure occur, and future studies should investigate the residual impacts of long COVID symptoms and conditions.

Disclosures

Natasha B. Halasa, MD, MPH, Genentech (Other Financial or Material Support, I receive an honorarium for lectures - it’s a education grant, supported by genetech)Quidel (Grant/Research Support, Other Financial or Material Support, Donation of supplies/kits)Sanofi (Grant/Research Support, Other Financial or Material Support, HAI/NAI testing) Natasha B. Halasa, MD, MPH, Genentech (Individual(s) Involved: Self): I receive an honorarium for lectures - it’s a education grant, supported by genetech, Other Financial or Material Support, Other Financial or Material Support; Sanofi (Individual(s) Involved: Self): Grant/Research Support, Research Grant or Support

581. COVID-19 Vaccine Perceptions in Adults from Greater Nashville Tennessee

Background

In December 2020, SARS-CoV-2 vaccines were made available to healthcare workers and soon thereafter offered to the general public according to age and risk of severe illness. Despite widespread access, vaccination rates vary by region, with Tennessee ranking lower than the national average. Therefore, we aimed to survey adults in greater Nashville, TN regarding SARS-CoV-2 vaccine perceptions.

Methods

We conducted a cross-sectional study of an ongoing longitudinal cohort of individuals with confirmed and/or suspected SARS-CoV-2 infection and their household contacts with enrollment onset in March 2020. For this analysis, individuals were included if they were ≥ 18 years and available for a one-year follow-up visit. At the one-year visit individuals completed a survey about vaccine preferences, beliefs and risks. Demographic and social characteristics were collected at enrollment. Individuals were considered vaccinated if they had received at least one dose of a SARS-CoV-2 vaccine under FDA emergency use authorization. Vaccine perceptions were compared by SARS-CoV-2-infection and vaccination status using Pearson’s chi-squared, alpha=5%.

Results

Between April-May 2021, 115 individuals completed the one-year follow-up. Table 1 includes sociodemographic characteristics of adults, of which the majority were vaccinated and were unemployed or in non-essential occupations. Most individuals agreed the SARS-CoV-2 vaccine can prevent infection and hospitalization (Figure 1A & B). Unvaccinated participants more often agreed that those who contracted SARS-CoV-2 should not receive the vaccine (30%), whereas vaccinated persons less often agreed (11%, p< 0.001) (Figure 1A). Additionally, 44% of unvaccinated individuals were neutral or disagreed that benefits of SARS-CoV-2 vaccination outweighed the illness risk, compared to 10% in the vaccinated group, p=0.001 (Figure 1A). Minimal differences of vaccine perceptions were observed between SARS-CoV-2 positive and negative adults (Figure 1B).

Table 1. Sociodemographic Characteristics of Adults

Figure 1. Vaccine perceptions of vaccinated and unvaccinated (A) SARS-CoV-2 positive and SARS-CoV-2 negative (B) adults in greater Nashville, TN. Vaccine perceptions were collected through a standardized survey at the one-year visit.

Conclusion

Although some unvaccinated individuals seemingly perceived the SARS-CoV-2 vaccine offered some protection, research should continue to evaluate the implications of vaccine hesitancy on the COVID-19 pandemic response as we prepare for the upcoming respiratory season.

Disclosures

Natasha B. Halasa, MD, MPH, Genentech (Other Financial or Material Support, I receive an honorarium for lectures - it's a education grant, supported by genetech)Quidel (Grant/Research Support, Other Financial or Material Support, Donation of supplies/kits)Sanofi (Grant/Research Support, Other Financial or Material Support, HAI/NAI testing) Natasha B. Halasa, MD, MPH, Genentech (Individual(s) Involved: Self): I receive an honorarium for lectures - it's a education grant, supported by genetech, Other Financial or Material Support, Other Financial or Material Support; Sanofi (Individual(s) Involved: Self): Grant/Research Support, Research Grant or Support

Comparing the Timeliness of Treatment in Younger vs. Older Patients with ST-Segment Elevation Myocardial Infarction: A Multi-Center Cohort Study

BACKGROUND

ST-segment elevation myocardial infarction (STEMI) predominantly affects older adults. Lower incidence among younger patients may challenge diagnosis.

OBJECTIVES

We hypothesize that among patients ≤ 50 years old, emergent percutaneous coronary intervention (PCI) for STEMI is delayed when compared with patients aged > 50 years.

METHODS

This 3-year, 10-center retrospective cohort study included emergency department (ED) STEMI patients ≥ 18 years of age treated with emergent PCI. We excluded patients with an electrocardiogram (ECG) completed prior to ED arrival or a nondiagnostic initial ECG. Our primary outcome was door-to-balloon (D2B) time. We compared characteristics and outcomes among younger vs. older STEMI patients, and among age subgroups.

RESULTS

There were 576 ED STEMI PCI patients, of whom 100 were ≤ 50 years old and 476 were > 50 years old. Median age was 44 years in the younger cohort (interquartile range [IQR] 41-47) vs. 62 years (IQR 57-70) among older patients. Median D2B time for the younger cohort was 76.5 min (IQR 67.5-102.5) vs. 81.0 min (IQR 65.0-105.5) in the older cohort (p = 0.91). This outcome did not change when ages 40 or 45 years were used to demarcate younger vs. older. The younger cohort had a higher prevalence of nonwhite races (38% vs. 21%; p < 0.001) and those currently smoking (36% vs. 23%; p = 0.005). The very young (≤30 years; 6/576) and very old (>80 years; 45/576) had 5.51 and 2.2 greater odds of delays.

CONCLUSION

We found no statistically significant difference in D2B times between patients ≤ 50 years old and those > 50 years old. Nonwhite patients and those who smoke were disproportionately represented within the younger population. The very young and very old had higher odds of D2B times > 90 min.

Establishing a High Throughput Epidermal Spheroid Culture System to Model Keratinocyte Stem Cell Plasticity

Epithelial dysregulation is a node for a variety of human conditions and ailments, including chronic wounding, inflammation, and over 80% of all human cancers. As a lining tissue, the skin epithelium is often subject to injury and has evolutionarily adapted by acquiring the cellular plasticity necessary to repair damaged tissue. Over the years, several efforts have been made to study epithelial plasticity using in vitro and ex vivo cell-based models. However, these efforts have been limited in their capacity to recapitulate the various phases of epithelial cell plasticity. We describe here a protocol for generating 3D epidermal spheroids and epidermal spheroid-derived cells from primary neonatal human keratinocytes. This protocol outlines the capacity of epidermal spheroid cultures to functionally model distinct stages of keratinocyte generative plasticity and demonstrates that epidermal spheroid re-plating can enrich heterogenous normal human keratinocytes (NHKc) cultures for integrinα6^hi/EGFR^lo keratinocyte subpopulations with enhanced stem-like characteristics. Our report describes the development and maintenance of a high throughput system for the study of skin keratinocyte plasticity and epidermal regeneration.

Understanding the Information Needs and Context of Trauma Handoffs to Design Automated Sensing Clinical Documentation Technologies: Qualitative Mixed-Method Study of Military and Civilian Cases

BACKGROUND

Current methods of communication between the point of injury and receiving medical facilities rely on verbal communication, supported by brief notes and the memory of the field medic. This communication can be made more complete and reliable with technologies that automatically document the actions of field medics. However, designing state-of-the-art technology for military field personnel and civilian first responders is challenging due to the barriers researchers face in accessing the environment and understanding situated actions and cognitive models employed in the field.

OBJECTIVE

To identify design insights for an automated sensing clinical documentation (ASCD) system, we sought to understand what information is transferred in trauma cases between prehospital and hospital personnel, and what contextual factors influence the collection, management, and handover of information in trauma cases, in both military and civilian cases.

METHODS

Using a multi-method approach including video review and focus groups, we developed an understanding of the information needs of trauma handoffs and the context of field documentation to inform the design of an automated sensing documentation system that uses wearables, cameras, and environmental sensors to passively infer clinical activity and automatically produce documentation.

RESULTS

Comparing military and civilian trauma documentation and handoff, we found similarities in the types of data collected and the prioritization of information. We found that military environments involved many more contextual factors that have implications for design, such as the physical environment (eg, heat, lack of lighting, lack of power) and the potential for active combat and triage, creating additional complexity.

CONCLUSIONS

An ineffectiveness of communication is evident in both the civilian and military worlds. We used multiple methods of inquiry to study the information needs of trauma care and handoff, and the context of medical work in the field. Our findings informed the design and evaluation of an automated documentation tool. The data illustrated the need for more accurate recordkeeping, specifically temporal aspects, during transportation, and characterized the environment in which field testing of the developed tool will take place. The employment of a systems perspective in this project produced design insights that our team would not have identified otherwise. These insights created exciting and interesting challenges for the technical team to resolve.

Feasibility Assessment of a Pre-Hospital Automated Sensing Clinical Documentation System

Clinical documentation in the pre-hospital setting is challenged by limited resources and fast-paced, high-acuity. Military and civilian medics are responsible for performing procedures and treatments to stabilize the patient, while transporting the injured to a trauma facility. Upon arrival, medics typically give a verbal report from memory or informal source of documentation such as a glove or piece of tape. The development of an automated documentation system would increase the accuracy and amount of information that is relayed to the receiving physicians. This paper discusses the 12-week deployment of an Automated Sensing Clinical Documentation (ASCD) system among the Nashville Fire Department EMS paramedics. The paper examines the data collection methods, operational challenges, and perceptions surrounding real-life deployment of the system. Our preliminary results suggest that the ASCD system is feasible for use in the pre-hospital setting, and it revealed several barriers and their solutions.